435201653-5-21-2024-26-AS-SRAI-D5H39E-20240521180302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201653
Report Date: 05/21/2024
Date Signed: 05/21/2024 06:03:15 PM

Document Has Been Signed on 05/21/2024 06:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	LSA - HOME #1		FACILITY NUMBER:	435201653
ADMINISTRATOR:	CHERYLL LAGUNILLA		FACILITY TYPE:	740
ADDRESS:	810 AGNEW RD		TELEPHONE:	(408) 988-8901
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY:	6	CENSUS: 5	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator, Cheryll Lagunilla		TIME COMPLETED:	06:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Cheryll Lagunilla. LPA Rai observed 3 staff and 5 residents at the facility. The facility has 5 elderly developmentally disabled residents who are overseen by San Andreas Regional Center. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1 degrees F - 114.1 degrees F. During tour, LPA Rai observed Clorox disinfecting wipes in multiple areas of the facility, such as the kitchen and resident room, which was accessible to residents at the facility. LPA Rai observed 2 resident which were non-ambulatory and were using a walker around the facility. LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai observed 2 out of 3 residents did not have a signed Appraisal/Needs and Services Plan by Licensee and Resident/Resident's Responsible Party on file. Continuation on LIC 809-C, Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

Document Has Been Signed on 05/21/2024 06:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LSA - HOME #1	FACILITY NUMBER: 435201653
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(a)

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in R3's 5 out of 7 medication not administered to R3 as prescribed by the MD which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit a written plan on understanding regulations, ensure staff administer medication as prescribed by the physician and schedule in-services training by POC date.

Type A

Section Cited

CCR

87207

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, interview and observation, R3's electronic MARs noted medications administered medication tablets counted in 5 out of 7 medication bottle were more than required, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Administration stated to submit a written plan on understanding regulations, ensure staff administer medication as prescribed by the physician and schedule in-services training by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 05/21/2024 06:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LSA - HOME #1	FACILITY NUMBER: 435201653
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above wherein 2 Clorox disinfecting wipe containers were located in the kitchen and resident bedroom accessible and not locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Administration stated to submit a written plan on understanding regulations, ensure disinfecting wipes are inaccessible to residents and schedule in-services training by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/21/2024 06:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LSA - HOME #1	FACILITY NUMBER: 435201653
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(b)

87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 resident file's contained an updated Apprasial/Needs and Services Plan dated 2022 which was not signed by Licensee and Resident/Resident's Reponsible Party which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2024
	Plan of Correction
1 2 3 4	Administration stated to submit a written plan on understanding regulations and ensure Appraisal/Needs and Services Plan is reviewed by resident/resident's responsible party and signed/dated by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LSA - HOME #1	FACILITY NUMBER: 435201653
	VISIT DATE: 05/21/2024

NARRATIVE

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LPA Rai reviewed resident medications and central stored medication records for 3 residents. LPA Rai observed 1 out of 3 resident (R3) has medication discrepancies wherein 5 out of 7 medication tablets in the bottle did not match the Central Stored Medication Record. Medication #1 should have 52 tablets in the bottle, LPA and Staff S1 observed 58 tablets, which meant there were 6 extra tablets in the bottle. Medication #2 should have 187 tablets in the bottle, LPA and Staff S1 observed 196 tablets, which meant there were 9 extra tablets in the bottle. Medication #3 should have 65 tablets in the bottle, LPA and Staff S1 observed 44 tablets, which meant there were 12 extra tablets in the bottle. Medication #6 should have 47 tablets in the bottle, LPA and Staff S1 observed 58 tablets, which meant there were 11 extra tablets in the bottle. Medication #7 should have 30 tablets in the bottle, LPA and Staff S1 observed 43 tablets, which meant there were 13 extra tablets in the bottle. LPA and S1 reviewed R3's Medication Administration Record (MARs) and staff initialed each dose, stating the resident was administered the medication and resident was not away from the facility.

Fire extinguisher was observed and inspected on 10/3/2023. Facility smoke detectors and carbon monoxide detector are in working condition. The last disaster drill was conducted on 4/18/2024.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Cheryll Lagunilla and a copy of the report was provided. Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5